Journal of Clinical & Experimental Dermatology Research
Open Access

Sex Hormones Assessment in Vitiligo Patient's Serum

Sherief Mahdy Hussein^1*, Mohammed Abd el Hakim Sorour², Ahmed Hossain³, Shaimaa Ahmed Abd el Azim⁴, Ahmed Soliman¹, Hany Shehata¹ and Noha Sami Hanafy^{1 *}Correspondence: Sherief Mahdy Hussein, Dermatology and Venereology Department, National Research Centre, Dokki, Giza, Egypt, Email:

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Introduction

Vitiligo is characterized by circumscribed, macules and patches of depigmentation which occurs due to distinct damage in melanocytes. It might happen at any time; patients were demonstrated as early as six weeks post labor. Its prevalence is similar in males and females, with no variance in degrees of appearance based on type of skin or race [1]. The pathogenesis of vitiligo is not well understood. There are several hypothesis about vitiligo etiology, involving autoimmune, neurohumoral, and autocytotoxic [2]. None are completely exclusive, each partially contributes. Convergence theory demonstrates that stress, infections, autoimmune diseases and the impairment of melanocyte migration can all implicate to the pathogenesis of vitiligo [1,3].

Vitiligo is a genetic acquired disease causing morbidity among all races. Nevertheless thyroid disorder plus other factors participate in its expression. Several hormones (corticotropin-releasing hormone, α-melanocyte-stimulating hormone, testosterone, estrogen), genes (Human Leukocyte Antigen (HLA), Estrogen Receptor (ESR) 1, Vitiligo-associated protein 1 (VIT1)), and lifestyle choices (stress, diet and cosmetic products) were assumed as motivators of this disorder [4].

Factors regulating production of pigment in skin are complicated and not well-understood. The color of the skin habitually alters during pregnancy, supposing that sex steroid hormones are implicated in this event, so that estrogen elevates the production of pigment in melanocytes of human, while progesterone reduces it [5].

Estrogens may be implicated in the course of depigmentation of vitiligo as the disease's initiation/progression is detected at pregnancy, or post contraceptives/hormonal substitution handling [6]. Immunomodulation is observed to be mediated by estrogen via alpha and beta receptors (ER α/β) of estrogen expressed on immune system cells. ERs affect function of immune system in both innate and adaptive immune response [7].

Serum levels ERβ were found to be statistically lesser in vitiligo female and male patients related to controls and also, estrogen levels were higher in patients related to controls [8]. The effect of a biological 17β-estradiol on these cells showed that, estrogens can enhance the number of melanocytes in epidermis, but reduce the content of melanin and activity of tyrosinase [9].

Testosterone-mediated pigmentation is still unknown. Histologic investigation demonstrates that, testosterone and sun exposure induces melanocytes, to elevate the production of melanin. Previously Shuttleworth et al. [10] indicating the relationship between methyltestosterone and acanthosisnigricans [10]. Hence, the present study aimed to assess the serum levels of both estrogen and testosterone, in vitiligo patients.

Subjects and Methods

Subjects

Depending on Hintze [11], who found that Mean ± SD of the Testosterone (nmol/L) in control and stable vitiligo 10.42 ± 1.85 and 5.20 ± 0.81 respectively, assuming the power=0.80 and ±=0.05, by using PASS 11^th release minimal sample size for an equal size a controlled clinical trial is 30 in each group.

Data are expressed as Mean ± S.D. Statistics is carried out using SPSS computer program version 22 combined with co-state computer program.

The study was carried out among 60 subjects attending the outpatient Dermatology Clinic of Medical research center of excellence of National Research Centre, Egypt, during a period of 4 months (August 2020 to November 2020). Contributors have written an informed approval. 30 patients with vitiligo lesions (18 males and 12 females; ages ranged from 28-40 years and 30 healthy volunteers as control group (17 males and 13 females; ages ranged from 25-40 years). A general dermatological examination was performed to decide distribution, site, number, and estimated surface area of lesions for all patients. Vitiligo was diagnosed clinically (presence of white milky macules and patches and confirmed with wood's light examination). Inclusion criteria include, male and female patients with vitiligo, ages from 20 to 40 years, stable disease for 1 year, patients not suffering from other autoimmune diseases, not receiving hormonal therapy in the last 3 months, not receiving ultraviolet therapy and psoralen in the last 3 months, not receiving any topical or systemic treatments in the last 3 months. History has been recorded about age, period, progress and start of disease, precipitating factors and any preceding treatment. Blood samples were obtained from both the patient and control groups. Testosterone and estrogen levels were examined. The study protocol followed the Declaration of Medical Division, National Research Centre (NRC); all subjects were informed about the study protocol. The study was approved by Ethics Committee of NRC, Cairo, Egypt with no"19- 031.

Laboratory assessment

Blood samples from patients and healthy individuals were obtained in EDTA-containing tubes and anticoagulant-free tubes. After centrifugation (3,000 g) for 10 min at 4, serum was separated in Eppendorf tubes and frozen at -80°C until analysis.

Human estradiol ELISA Core Kit and testosterone ELISA kit (Biopark, Optics Valley, and Wuhan, CHINA and ALPCO immunoassays, USA respectively) were used for measuring serum estrogen and testosterone.

Results

Table 1 shows that in a group of 60 subjects (30 patients and 30 controls). A study was carried out to estimate the levels of testosterone and estrogen in subjects suffering from vitiligo. A student T test was carried out for 2 independent means at P<0.05 which clarified a significant increase in levels of testosterone in male patients but no difference in female ones; however, estrogen levels showed a significant elevation in female patients rather than males which revealed no difference.

Table 1: Comparison between levels of testosterone and estrogen in both case and control subjects.

Discussion

The vitiligo etiology is complicated and still unknown. Different hypothesis were suggested to illustrate the loss of melanocyte function [12]. As a result of the disturbances in neural and endocrinal status, other reasons involving; an autoimmune disorders, an alteration in the homeostasis of tetrahydrobiopterin (BH₄) [13], stressors of psychological condition [14] and defective in the defense mechanism for free radical on melanin production [15]. Schallreuter [16] revealed that keratinocytes of human synthesize and/or breakdown catecholamines. In this mechanism, tyrosine was spilt into melanin and catecholamine by tyrosine hydroxylase enzyme (signaling of neural molecules; DA, NE, etc., that regulate central and peripheral nervous systems) [17].

The present study declared significant increase in testosterone levels in male VP but not in females compared to control. While marked significant increase in estrogen levels in female VP but not in males compared to control.

In a good connection with the present results El-Sayed et al. [15], indicated that the relationship between elevated levels of catecholamine and the process of depigmentation was illustrated by a biochemical theory demonstrated high levels of the (6R)- l-erythro 5,6,7,8-tetrahydrobiopterin (6BH₄) in epidermis of vitiligo which occurred as a consequence of enhancement in the catecholamine biosynthesis instead of melanin and formation of H₂O₂, which is melanocytes lethal agents resulting in autoimmune reaction. Moreover, biopterins act as inhibitors of the phenylalanine hydroxylase and tyrosinase enzymes implicated in the process of melanogenesis [18]. High levels of catecholamines cause vasoconstriction leading to hypoxia of epidermal-dermal tissue, and produce high levels of ROS (reactive oxygen species) and systemic H₂O₂ levels resulting from monoamine oxidation as well as their metabolites might contribute to early phase of melanocyte damage in vitiligo pateints [18,19]. Moreover, El Sayed et al. [15], illustrated that, elevated catecholamines, DA, estrogen, and prolactin levels as a consequence of hyper- H₂O₂ production leads either to stimulation of immune response versus melanocytes (depigmentation) or to inactivation of BH₂ reductase and BH₄ cofactor (reduced pigmentation), enhanced catecholamines stimulate biosynthesis of melatonin or activate its receptors. Furthermore, the high levels of estrogen in VP might occur as a consequence of oxidative stress principally H₂O₂ is detected in VP skin and blood as demonstrated by Rokos et al. [20], (as detected in the existing research) which is strongly implicated in the course of depigmentation of vitiligo [21]. In addition, an important enzyme, BH₂ reductase, involved in the recycling of (6R)-l-erythro-5,6,7,8- BH₄ cofactor and was inactivated by H₂O₂ [22,23]. In contrast, melasma (facial pigmentation of grayish brown color) might appear in females using oral contraceptive pills containing analogs of steroid hormone supposing that, human pigmentation is regulated by an element other than α-MSH as estrogen. So, it acts as a ligand, affecting production of melanin through its receptors on melanocytes [15]. Accordingly, elevated estrogen levels in females at child-bearing age makes them less liable to vitiligo as reported by Kang and Ortonne [24].

In contrast declared the association between the lack of fertility and vitiligo, so in hypogonadism of male; the inadequate production of testosterone hormone leads to infertility. The same authors added that, the reduction in serum testosterone in males with active or stable VP results from emotional distress and low self-confidence affecting their sexual life.

Conclusion

Current study presents a competent approach for understanding the progress of vitiligo through a trial explaining the mechanism(s) of incidence and the role of specific biomarkers contributing to its progress. Also, we indorse that any dermatologist should consider neurological, psychological, and endocrine disorders which may influence either progression or improvement of the disease.

References

1. Alikhan A, FelstencL M, Daly M, Petronic-Rosi V. Vitiligo: A comprehensive overview. J Am Acad Dermatol. 2011;65:473-491.
2. Alkhateeb A, Fain PR, Thody T, Bennett DC, Spritz RA. Epidemiology of vitiligo and associated autoimmune diseases in caucasian probands and their families. Pigment Cell Res. 2003;16:208-214.
3. Le Poole IC, Das, PK, van den Wijngaard RM, Bos JD, Westerhof W. Review of the etiopathomechanism of vitiligo: a convergence theory. Exp Dermatol. 1993;145-153.
4. Patel S, Rauf A, Khan H, Meher BR, Hassan SSU. A holistic review on the autoimmune disease vitiligo with emphasis on the causal factors. Biomed Pharmacother. 2017;92:501-508.
5. Natale CA, Duperret EK, Zhang J, Sadeghi R, Dahal A, O'Brien KT, et al. Sex steroids regulate skin pigmentation through nonclassical membrane-bound receptors. eLife. 2016;5.
6. Salzer BA, Schallreuter KU. Investigation of the personality structure in patients with vitiligo and a possible association with impaired catecholamine metabolism. Dermatology. 1995;190:109-115.
7. Cunningham M, GilkesonG. Estrogen receptors in immunity and autoimmunity. Clin Rev Allergy Immunol. 2011;401: 66-73.
8. Sabek NA, Eyada MM, Aziz SMA, Demerdash SM, Goma AH, Fikry S. Serum estrogen and estrogen receptor beta levels in female and male patients with vitiligo. Am J Biomed Res. 2015;3:53-57.
9. McLeod SD, Ranson M, Mason RS. Effects of estrogens on human melanocytes in vitro. J Steroid Biochem Mol Biol. 1994;49:9.
10. Shuttleworth D, Weavind GP, Graham-Brown RA. Acanthosis nigricans and diabetes mellitus in a patient with klinefelter’s syndrome: a reaction to methyl testosterone. Clin Exp Dermatol. 1987;288-290.
11. Mohammed GF, Gomaa AHA, Al-Dhubaibi MS. Highlights in pathogenesis of vitiligo. World J Clin Cases. 2015;3:221-230.
12. Schallreuter KU, Moore J, Wood JM, Beazley WD, Eva M, Peters J. Epidermal H2O2 accumulation alters tetrahydrobiopterin (6BH4) recycling in vitiligo: Identification of a general mechanism in regulation of all 6BH4-dependent processes? J Invest Dermatol.2001;116:167-174.
13. Silverberg JI, Silverberg NB. Vitiligo disease triggers: psychological stressors preceding the onset of disease. Cutis. 2015;95:255-262.
14. El-Sayed M IK, Abd El-Ghany AA, Mohamed RR. Neural and endocrinal Pathobiochemistry of vitiligo: Comparative Study for a hypothesized mechanism. Front Endocrinol (Lausanne). 2018;9:197.
15. Schallreuter KU. Epidermal adrenergic signal transduction as part of the neuronal network in the human epidermis. Dermatol Symp Proc. 1997;2:37-40.
16. Slominski AMD, Zmijewski M, Pawelek J. L-tyrosine and L-DOPA as hormone-like regulators of melanocytes functions. Pigment Cell Melanoma Res. 2012;25:14-27.
17. Laddha NC, Dwivedi M, Mansuri MS, Gani AR, Ansarullah M, Le Poole IC, et al. Review of the etiopathomechanism of vitiligo: a convergence theory. Exp Dermatol. 1993;2:145-153.
18. Denat L, Kadekaro AL, Marrot L, Leachman SA, Abdel-Malek ZA. Melanocytes as invstigators and victims of oxidative stress. J Invest Dermatol. 2014;134:1512-1518.
19. Rokos H, Beazley WD, Schallreuter KU. Oxidative stress in vitiligo: photo-oxidation of pterins produces H2O2 and pterin-6-carboxylic acid. Biochem Biophys Res Commun. 2002;292:805-811.
20. Anderson D, Schmid TE, Baumgartner A, Cemeli-Carratala E, Brinkworth MH, Wood JM. Oestrogenic compounds and oxidative stress (in human sperm and lymphocytes in the comet assay). Mutat Res. 2003;544:173-178.
21. Cucchi ML, Frattini P, Santagostino G, Preda S, Orecchia G. Catecholamines increases in the urine of non-segmental vitiligo especially during its active phase. Pigment Cell Res. 2003;16:111.
22. Schallreuter KU, Elwary SMA, Gibbons NCJ, Rokos H, Wood JM. Activation/deactivation of acetylcholinesterase by H2O2: more evidence for oxidative stress in vitiligo. Biochem Biophys Res Commun. 2004;315:502-508.
23. Kang HU, Ortonne JP. What should be considered in treatment of melasma. Ann Ermatol. 2010;22:373-378.